The most prominent guidelines recommend shared decision making after a thorough discussion about the potential benefits and risks of PSA screening. These recommendations reaffirm this position. Routine screening would imply no particular dialogue and use of screening in all healthy adults, and there is near universal agreement that the available data do not support this. However, the available studies have significant limitations, among the control arms including some screening and importantly the absence of more modern approaches to management of prostate cancer which decouple diagnosis from treatment and include observation. Prostate cancer screening remains a vexing challenge and better tests are needed. For men who chose to be screened, thoughtful and careful consideration of what to do if a cancer is diagnosed is essential.